The Scope of Nursing Practice in Level III Neonatal Intensive Care Units

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ABSTRACT.A structured,timed,telephonesurveyto determine the scope of nursing practice in level ifi neo natal intensive care units revealed that the staff/head nurse and neonatal nurse clinician/specialist now are responsible for a wide variety of sophisticated skills and procedures, which were heretofore usually performed by a physician. This study has broad implications for edu cational as well as service activities and indicates a need to change physician and nurse expectations and education accordingly. Pediatrics 70:875â€”878,1982; nurse, neonatal

nurse clinician, expanded nursing role.

In the last ten years major changes have occurred in the delivery of health care to newborn infants and have affected the practicing pediatrician as well as the methods of came.'5 Neonatology has emerged as a subspecialty as well as an important part of pediatrics.6 Concurrently, dynamic changes appear to be occurring in neonatal nursing. In-house con tinuing education programs, extramural continuing education certificate courses, as well as master's and doctorate level curricula, have been developed and supported by both the medical and nursing pmofessions.79 The actual role of the in-house-edu cated staff/head nurse and/or the neonatal nurse clinician/specialist in the clinical setting is not clear. Many interested parties, including the Commit tee on Fetus and Newborn and the Section on Perinatal Pediatrics of the American Academy of Pediatrics, have been interested in an objective assessment of the nursing mole in neonatal intensive care. An earlier postal survey provided some infor

Received for publication April 22, 1980;accepted Jan 27, 1982. Reprint requests to (R.G.H.) North Shore University Hospital, 300 Community Drive, Manhasset, NY 11030.

mation.'Â°This study was undertaken to provide an objective, comprehensive, in-depth analysis of the nursing role in neonatal intensive care. It was hoped that these data would serve to facilitate subsequent discussion as to the needs, requirements, and me sponsibilities of the staff/head nurse and neonatal nurse clinician/specialist.

METHODOLOGY

A structured, timed, telephone survey consisting of 20 multiple-choice questions divided into two sections was developed. Specific questions were de signed to elicit information concerning the size of the neonatal intensive care units surveyed, the quantity of infants served, the number of nurses involved per unit and their teaching, research, and service responsibilities, the mechanism by which neonatal intensive care units define responsibilities, and the educational background, salary range, and length of employment of the nurses in the unit.

Specific attention was directed toward activities and responsibilities that the head/staff nurse or the neonatal nurse clinician/specialist assumed inde pendently. Questions were asked in a standardized manner with the questions related to procedures and responsibilities (Table) as follows: â€œ¿Doesthe head/staff nurse or neonatal nurse dlinician/spe cialist perform any of these tasks independently, ie, make judgments and/or act without the physi cian?â€•When the respondent was unclear as to the definition of independence, the interviewer ex plained that the nurse could be functioning inde pendently, without the presence or consultation of a physician, under a previously agreed-upon proto col. Each of the 20 specific responsibilities and skills was considered individually.

The directors of neonatology or neonatologists

PEDIATRICS Vol. 70 No. 6 December 1982 875

The Scope of Nursing Practice in Level Ill

Neonatal Intensive Care Units

Rita G. Harper, RN, MD, George A. Little, MD, and Concepcion G. Sia, MD

From the Departments of Pediatrics and Obstetrics and Gynecology, North Shore University Hospital, Manhasset, New York, and Cornell University Medical College, New York; and Department of Maternal and Child Health, Dartmouth Medical School, Hanover, New Hampshire

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TABLE. Percentof InstitutionsReportingIndepend

ently PerformedResponsibilitiesProcedureStaff!NeonatalHeadNurseProcedures and Cli Nursenician/(N

= M)@Specialist(N = 31)1.

Perform exchange transfu 255sion

with nurse as primaryoperator2.

Perform lumbar puncture4583.

Perform endotracheal or na 774sotracheal intubation4. Perform umbilical artery1781catheterization5. Determine respirator setting1961changes6.

Perform umbilical vein cath 1984eterization7. Initiate continuous positive1965airway pressure (CPAP) orother ventilation procedures8. Give emergency medication2287for seizures, hypoglycemia,etc

(eg, phenobarbital, glu cose)9. Release pneumothorax by2674needle aspiration10. Start phototherapy288411. Order roentgenograms378412. Perform arterial puncture489313.

Perform physical examina 59100tion14. Transilluminate the skull599415. Perform venipuncture7210016. Assess gestational age8010017.

Give nonemergency intrave 8797nous

medication18. Draw blood from umbilical93100arterial catheter19. Administer blood949720. Start peripheral intravenous94100infusion

icate program, but who may have attended semi nars, in-house training sessions, or other advanced educational courses to upgrade knowledge and skills. The neonatal nurse clinician/specialist was defined as a registered nurse who had completed a formal certificate, master's or doctoral degree pro gram; the designation did not include registered nurses who attended seminars or short-term or on the-job training programs.

RESULTS

Institutional Data

From the predetermined randomly selected 55 institutions, all but one neonatologist (98.1%) agreed to participate. The neonatologists mepre sented institutions from 33 states. The median in stitution surveyed had 2,450 deliveries per year with the minimum being zero deliveries per year, ie, a total transport-in NICU, and the maximum being 14,000 deliveries per year. The median daily neo natal intensive care unit census was 22 with a mange of seven to 58 infants per day. The median number of transports into the units surveyed was 175 per year with a mange of 0 to 1,000 transports per year. The 54 neonatal intensive care units surveyed me ported employing 2,663 nurses. The median number of nurses per unit was 45 with a maximum of 120 per unit. Theme were 89 neonatal nurse clinician! specialists who were employed in 31 institutions, with one unit employing 12 and 12 units employing one nurse clinician/specialist. The remaining 65 neonatal nurse clinicians were distributed among the other units.

Staff/Head Nurse Data

Of the neonatologists interviewed, 80% stated that in their institution the scope of responsibility of the staff/head nurse had expanded during the past five years. Both nurses and physicians were reported to be involved in developing in-house training programs for expansion of the nursing mole by 79% of the respondents.

The procedures and responsibilities that were reported by the responding neonatologists to be performed independently by the staff/head nurse without direct supervision or involvement of a phy sician are shown in the Table. Of those listed, items 13 through 20 were performed independently by staff/head nurses in at least 50% of the institutions. A manual or protocol reference book, which defined the independent function of the nurse, was present in 84% of the institutions.

Ofthe neonatologists queried, 59% expressed con cern about increased legal liability of the nurse in this expanded mole. Despite this concern, 24% of the neonatologists did not know whether the head/staff * N = number of reporting institutions.

from 20% of the known 278 neonatal intensive care units (NICUs) in the United States'1 were randomly selected to be surveyed. After the initial telephone contact, an appointment was made to conduct the interview at a mutually convenient time. A pretest was administered to ensure internal consistency between interviewers. All interviews were con ducted during November 1980 through January 1981. Test administration time was limited to 15 minutes.

A two-part structure was necessary to determine whether differences exist between the moleof the in house-educated staff/head nurse and the formally educated neonatal nurse clinician/specialist. The staff/head nurse was defined as a registered nurse who had not attended a formal educational program to increase knowledge or skills, ie, a nurse who had not completed a master's, doctoral, perinatal nurse clinician, nurse specialist, or other degree or certif

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nurse involved in this expanded mole carried per sonal liability insurance.

The neonatologists reported that they themselves had accepted the increased responsibilities of the staff/head nurse (97%) whereas the practicing pe diatrician and nurse supervisors were less accepting (61% and 70%, respectively). Of the respondents, 80% said that the house officers were accepting of the expanded role.

Neonatal Nurse Clinician/Specialist Data

Of the 54 institutions surveyed, 31 reported that at the time of the survey the institution had on staff at least one neonatal nurse clinician/specialist. More than half of these centers reported employing at least one nurse clinician/specialist for more than one year. A number of institutions reported that they had hired a neonatal nurse clinician/specialist in the past or that they planned to hire one in the future. Only the data from the 31 institutions who reported having a neonatal nurse clinician/special ist on staff are presented here.

The procedures and responsibilities that were reported by the responding neonatologists to be performed independently by the neonatal nurse clinician/specialist without direct supervision of the physician are shown in the Table. All 20 items were performed independently by the neonatal nurse clinician/specialist in at least 50% ofthe institutions questioned. A manual or protocol reference book, which defined the independent function of the neo natal nurse clinician/specialist, was present in 74% of the institutions.

Of the neonatologists questioned, 74% reported concern about increased legal liability of the neo natal nurse clinician/specialist. Again, 19% of the neonatologists did not know whether the neonatal nurse clinician/specialist in their institution carried personal liability insurance.

Supervision for the neonatal nurse clinician/spe cialist was administered under nursing in 19% of the institutions, pediatrics in 39% of the institutions, and jointly by nursing and pediatrics in 39% of the institutions.

The majority of the neonatal nurse clinician/spe cialists worked under that job title. Only 11 of the 89 clinicians held other job titles including nursing instri: @tom(one), staffnurse (four), head nurse (one), and transport nurse (five).

In 81% of the institutions, the neonatologist me ported that in his or hem opinion the neonatal nurse clinician/specialist was able to replace a pediatric house officer. Approximately haiffelt that the nurse clinician could replace a level I pediatric resident, with the remainder feeling that the neonatal nurse clinician could replace a level II pediatric resident.

In 48% of the institutions, the neonatal nurse cii cian/specialist was actually employed to replace the house officer.

Approximately half of the institutions presently employing neonatal nurse clinicians required clii cians to attend off-site postgraduate educational programs.

A teaching component was reported to be a part ofthe moleof the neonatal nurse clinician/specialist: 35% taught nurses only, another 35% taught nurses and house officers, and a surprising 22% also taught attending physicians.

All of the responding neonatologists with neo natal nurse clinician/specialists on their staff at the time of the survey accepted the mole. In addition, they reported acceptance by 71% of nursing super visors, 97% of staff nurses, 71% of house officers, and 58% of the practicing pediatricians. Of the neonatologists in institutions already employing neonatal nurse clinician/specialists 76% would like to hire more if financially able; 23% would hire as many as five to six additional neonatal nurse clii cian/specialists.

DISCUSSION

The results document that the scope of neonatal nursing practice now encompasses a knowledge base and technical skills that were traditionally considered the province of the physician. Extrapo lation of our data indicates that approximately 57% of the 278 level III units in the United States presently employ neonatal nurse clinicians and that these 278 level III units employ 445 neonatal nurse clinician/specialists. We documented a strong in dication that many units would hire additional neo natal nurse clinicians if financially able to do so. In fact, during the process of performing the survey, we were asked if we knew of available individuals.

The information derived from this study has broad implications for educational as well as service activities. Continuing postgraduate educational courses must be developed for nurses presently engaged in expanding neonatal roles in order that skills and knowledge keep pace with the demands of the field.

The moleof the neonatal nurse clinician/specialist in the education of physicians is documented. Al though in the past nurses taught physicians in an ad hoc fashion, use of nurses as formally designated educators of physicians is a new concept. The need for adequate training for this educational mole is apparent.

This study indicates that more procedures are being performed by nurses, that there is widespread interest in employing a larger number of nurse clinician/specialists, and that nurses are replacing

ARTICLES 877 at Viet Nam:AAP Sponsored on September 7, 2020

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house officers in a variety of moles. Concerns about involvement ofpediatric house officers'2 in neonatal intensive care units are clearly related to the service and educational role of nurses. A positive aspect of this trend may be the relief of certain perceived excesses in the use of pediatric house officers for service-related activities. The number and function of neonatal nurse clinician/specialists should be carefully related to the quality of pediatric training in neonatology so as not to detract from adequate preparation of house officers to function in general pediatric practice. In addition, it must allow for growth, development, and satisfaction of the neo natal nurse clinician/specialist within the nursing profession.

The involvement of members of the nursing profession in tasks previously assigned to physicians raises many questions concerning medicolegal is sues. These will require attention and will be resist ant to resolution until educational programs with consistent core knowledge are developed.

A legitimate concern regarding this study is that information about nursing moles was provided by the neonatologist. Although this concern must be considered in interpretation, the overall body of information indicates that the majority of mespon dents in one profession (medicine) perceive a change in another profession (nursing) and that these changes involve a broadening of nursing prac tice to include procedures and responsibilities pre viously associated with medicine.

The future will seemingly include expanded-mole staff/head nurses and neonatal nurse dlinician/spe cialists in neonatal medicine. Historically, medicine has encountered similar situations in the develop ment of nurse midwives as well as pediatric nurse practitioners. Once again, concerns have arisen which must be resolved through joint effort if mu tual professional respect is to be achieved.'3 Many questions concerning the optimal patient care and

educational standards required for the neonatal nurse clinician, the mechanism for advancement, and the areas of responsibility remain to be an swemed. Nursing must, of course, provide primary leadership in the resolution of these issues. Physi cians, specifically pediatricians, must be included in these efforts which include certification, as the role has joint nursing and pediatric accountability. Ev olution toward the expanded role ofstaffnurses and neonatal nurse clinician/specialists must be flexible enough to allow variation and experimentation while at the same time meeting the needs of stan dardization of educational requirements and service responsibilities.

REFERENCES

1. Klaus M, Fanaroff AA: Care of the High Risk Neonate, ed 2. Philadelphia, WB Saunders, 1979

2. Harper RG, Yoon J: Handbook of Neonatolo@y. Chicago, Year Book Medical Publishers, 1974

3. Philip AGS: Neonatology, ed 2. Garden City, NY, Medical R@mination Publishing Co, 1980

4. Avery G (ed): Neonatology, ed 2. Philadelphia, JB Lippin cott, 1981

5. Harper RG: Taking the task force to task, letter. Pediatrics 63:952, 1979

6. COmmittee on Fetus and Newborn and Committee of the Section on Perinatal Pediatrics: Estimates of need and rec ommendations for personnel in neonatal pediatrics. Pediat

rics 65:850, 1980

7. Neonatal nurse practitioners, editOriaL BrMedJ 1:115, 1975 8. Johnson PA, Jung A!, Bores SJ: Neonatal nurse practition

era:A new expanded nursing role. Perinatol/Neonatol 3:45, 1979

9. Ostrea EM Jr, Schuman H: The role of the pediatric nurse on a neonatal unit. J Pediatr 84:628, 1975

10. Sia C, Little GA, Harper R, et al: Has nursing practice changed in the NICU? abstracted. Pediatr Res 14:517, 1980 11. 1979 Guide to Referral Centers Providing Perinatal and

Neonatal Care. Columbus, OH Ross Planning Associates, Ross Laboratories, 1979

12. The Future ofPediatric Education: A Report by the Task Force on Pediatric Education. Evanston, IL@American Academy of Pediatrics, 1979

13. Dunn BH: Pediatricians and pediatric nurse practitioners! associates: Growth of collegial relationships. Pediatrics 63:819, 1979

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1982;70;875

Pediatrics

Rita G. Harper, George A. Little and Concepcion G. Sia

The Scope of Nursing Practice in Level III Neonatal Intensive Care Units

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1982;70;875

Pediatrics

Rita G. Harper, George A. Little and Concepcion G. Sia

The Scope of Nursing Practice in Level III Neonatal Intensive Care Units

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